Mr S.L. (Hospital RN: 140897)

81 years old gentleman, fit, still able to care for self independently. Known to have hypertension, dyslipidemia, CKD stage 4.He presented with chest pain since early 2021. Three hospitalizations in May 2021 and readmission in October 2021. Vital signs were stable during all admissions. Cardiac enzymes never raised. ECG no significant changes. Treated as Unstable angina. 

Blood investigations revealed urea 14mmol/L, creatinine of 200 micromoles/L. Other than that HB 10g/dL. Others were normal.His chest x-ray was unremarkable, no widened mediastinum or mass or consolidation.ECG were non dynamic and no significant changes noted.Echocardiography revealed preserved LVEF with no significant valvular lesions.

WhatsApp Video 2021-11-24 at 9.54.39 PM.mp4
WhatsApp Video 2021-11-24 at 9.59.40 PM.mp4

Subclavian artery-aorta entry very tortuous.Left main stem was normal.Left anterior descending artery was proximally occluded.Left circumflex artery was non dominant and proximally occluded.Right coronary artery was dominant, proximal mild disease. Distal 70-80% at the crux. PDA and PLV mild disease. Supply collaterals to the left coronary artery.
LCA2.mp4
Spider view5.mp4
RCA6.mp4

Right radial artery punctured. 6Fr sheath inserted. After diagnostic angiogram, decided for ad hoc PCI of the RCA. 6Fr JL 3.5 GC used to engage RCA. BMW guidewire is passed and able to reach till LAD CTO. RCA lesion predilated and stented. Subsequently, decided to PCI LAD CTO. The BMW guidewire left in situ. The guidewire is removed over long exchange guidewire technique. 6Fr radial sheath was upsized to 7Fr. The RCA wire was externalized to the radial sheath. 6Fr EBU 3.5 GC was railroad over the long exchange GW due to the very tortuous subclavian artery. LCA is engaged. LAD CTO was attempted with PILOT150 GW but unsuccessful. Decided to use Finecross microcatheter, this time PILOT 150 wire entered false lumen. GAIA second wire was used and crossed D1. A BMW wire was exchanged with GAIA second after confirming the position with contrast through microcatheter. With the previous retrograde BMW (from RCA) roadmap in LAD and now new BMW in D1, the LAD CTO was successfully crossed with GAIA second support with Finecross. The BMW wire from RCA (externalized from sheath) was then removed and exchanged with GAIA and advanced into LAD and retrograde to RCA and aorta to provide support. The lesion serially predilated with 1.0mm, 2.0mm and 3.5mm x 15mm length. Scoreflex NC. POBA from ostial to mid LAD. D1 POBA as well. Antegrade flow of LAD restored. Treated with DEB Sequent Please Neo 3.5mm x 40mm. D1 KBT with 2.0mm balloon.
LAD lesion crossed with GAIA second. D1 and retrograde BMW in situ..mp4
Post DEB.mp4
Final LAD results.mp4

A complex lesion, in this case two vessels were treated at same settings, RCA and CTO of LAD. We have managed to do it via radial approach sparing the femoral. This patient has high bleeding risk as he is elderly with CKD and the patient has strongly refused CABG on table. Given that he is from a district far from a PCI center, we have decided to proceed to treat the lesions ad hoc to help relieve his symptoms so that he can continue to live as independent as before. We have managed to save a lot of cost as well by using minimal tools with one radial puncture and as safe as possible especially in an elderly. We have left the RCA wire in situ as reference for crossing the LAD CTO.
Thank you.